Intensified tuberculosis case finding among people living with the human immunodeficiency virus in a hospital clinic in Ethiopia.

Intensified tuberculosis case finding (ICF) is used in people living with the human immunodeficiency virus (PLHIV) to reduce the burden of tuberculosis (TB). We conducted a retrospective study in 300 PLHIV attending an HIV care clinic in Ethiopia to assess ICF performance during a 12-month period. Between 80% and 95% of patients were screened for TB at enrolment and at each 3-month follow-up visit. Thirty-four (11%) patients were diagnosed with TB, of whom 27 (79%) were identified in the first 6 months. This study assessed serial ICF in routine settings, showing that TB screening had its largest diagnostic yield in the first 6 months.

Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia.

OBJECTIVE: To determine the clinical outcome of bipolar disorder in a developing country setup. METHOD: After assessing 68 378 individuals, aged 15-49 years, in a double-sampling design in a rural community in Ethiopia, 312 patients with bipolar disorder were prospectively monitored with symptom rating scales and clinically for an average of 2.5 years. RESULTS: Overall, 65.9% of the cohort experienced a relapse--47.8% manic, 44.3% depressive and 7.7% mixed episodes--and 31.1% had persistent illness. Female gender predicted depressive relapse, while male gender predicted manic relapse. Being on psychotropic medication was associated with remission. CONCLUSION: This large community-based study confirms the relapsing nature of bipolar disorder and a tendency for chronicity. This may be partly because of lack of appropriate interventions in this setting; however, it may also indicate the underlying severity of the disorder irrespective of setting.

Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia.

BACKGROUND: Prospective outcome studies based on a community sample of mostly neuroleptic naive cases of schizophrenia are uncommon. OBJECTIVES: To describe short-term symptomatic and functional outcomes of schizophrenia, and potential predictors of outcome. METHODS: After a baseline assessment, 63 incident and 208 prevalent cases of schizophrenia were followed by a yearly clinical assessment for an average of 2.5 (range 1-4) years. Scores of negative symptoms and positive symptoms were used as indicators of symptomatic outcomes. SF-36 scores of physical and social functioning, and role limitation due to mental health problems were used as indicators of functional outcomes. Several variables were evaluated as potential predictors of outcome in random coefficient models. RESULTS: Functioning and other measures of health related quality of life were significantly diminished in cases as compared to the general population of the area at baseline and follow up. Of the socio-demographic and clinical factors evaluated, only lower negative and positive symptom scores were significantly associated with improvements in functioning. The level of functioning observed in cases from Butajira was lower than that reported for cases from developed countries. CONCLUSIONS: Our findings are not in accord with other outcome studies that have reported better functional outcome for cases of schizophrenia from developing countries.

Socio-demographic correlates of bipolar disorder in Butajira, rural Ethiopia.

OBJECTIVES: To describe the socio-demographic correlates of bipolar disorder and their interactions. DESIGN: Cross sectional study. SETTING: Rural population in Ethiopia. SUBJECTS: We conducted a door-to-door survey of a predominantly rural population of close to 70,000 individuals. A total of 315 cases of bipolar disorder were identified by use of the SCAN and clinical assessment. RESULTS: The lifetime prevalence of biopolar disorder in this population was 0.5% (0.6% for men and 0.4%) for women. Adjusted odds ratios show that males had 80% higher risk of bipolar disoder: OR (95% CI) = 1.81 (1.42, 2.32). Those aged 25-34 years had 45% higher risk than those aged under 25: adjusted OR (95% CI) = 1.45 (1.03, 2.06). Area of residence and educational level were not associated with the disorder. The association of marital status with bipolar disorder was modified by age and sex. Among males the odds of bipolar disorder among the married was 3.6 times higher than those who have never married. Among the age group of 15 to 24 years, those married had a 84% higher risk of disease, while those previously married had a 55% increase. On the other hand the association between marital status and bipolar disorder is reversed in older age groups, with those who have never married having a higher risk compared to those married. CONCLUSION: The study shows that the prevalence of bipolar disorder in this population is within ranges of prevalence reported in the literature, although on the lower side. It also shows that age, sex and marital status are associated with bipolar disorder and these variables interacts with each other.

Prevalence and clinical characteristics of bipolar I disorder in Butajira, Ethiopia: a community-based study.

BACKGROUND: Bipolar disorders have been extensively studied in the high-income countries but community-based studies from low-income countries are very rare. The main objectives of the current study are to estimate the lifetime prevalence of bipolar I disorder in the general population of the Butajira district in Ethiopia and to characterize the onset and course of the disorder in a predominantly treatment naïve population. METHOD: Cases were identified by a door-to-door screening of the district's entire adult population aged 15 to 49 years (N=83,387), where 68,378 were successfully screened. CIDI and key informant method were used in the first stage of screening followed by confirmatory SCAN interviews. RESULTS: Three hundred fifteen cases were identified and complete information could be collected for 295 individuals. Of these, 55.3% were males, 83.1% were from a rural area, and 70.2% were illiterate. Lifetime prevalence of bipolar I disorder was estimated to be 0.6% for males and 0.3% for females. The mean age of cases was 29.5 years, with no significant sex difference. The mean age of first recognition of illness was 22.0 years; for men 22.3 years and for women 21.2 years. The mean age at onset of manic phase of the illness was found to be 22.0 years (22.5 for men and 21.4 for women). The mean age at onset of depressive phase was 23.4 years (24.1 for men and 22.5 for women). There was no significant sex difference in the age of onset of manic or depressive phases. In 22.7% of the cases bipolar I illness started with a depressive episode and in 77.3% of the cases it started with a manic episode. Two or more episodes of the illness were reported by 64.1%. Over half of the study subjects (55.9%) had never sought any help from modern healthcare sector, and only 13.2% had ever been admitted to psychiatric hospital. During the survey 7.1% of the cases were undergoing treatment. A previous suicide attempt was reported by 8.1% of the males and 5.4% of the females. CONCLUSION: The overall lifetime prevalence and age of onset are within the range of findings from other studies in Western countries. In contrast to most previous studies, prevalence of the disorder among females was half of that among males. Our finding that prevalence of this disorder among males and females appeared to be different from many other studies warrants further research.

Neurological soft signs in bipolar I disorder patients.

BACKGROUND: Neurological soft signs (NSS) have been reported to be more prevalent in patients with schizophrenia compared to other psychiatric and non-psychiatric controls. However, this issue in bipolar I disorder seems to be understudied. AIMS: The aims of the study were to examine the extent to which NSS are associated with bipolar I disorder cases compared to healthy controls, to assess the possible relationship between NSS and clinical dimensions of the disorder, and to explore the association of sociodemographic characteristics with the occurrence of NSS in cases with this disorder. METHODS: Predominantly treatment naïve cases of bipolar I disorder from rural communities were assessed for NSS using the Neurological Evaluation Scale (NES). RESULTS: This study showed that patients with bipolar I disorder performed significantly worse on two NES items from the sensory integration subscale, on one item from motor coordination and on four items from the 'others' subscale, the highest difference in performance being in items under the sequencing of complex motor acts subscale. Clinical dimensions and sociodemographic characteristics appeared to have no relationship with NES total score. CONCLUSIONS: Bipolar I disorder patients seem to have more neurological dysfunction compared to healthy controls particularly in the area of sequencing of complex motor acts. In addition, the finding suggests that NSS in bipolar I disorder are stable neurological abnormalities established at its onset or may be essential characteristic features of the disorder representing stable disease process that existed long before its onset.

Onset and clinical course of schizophrenia in Butajira-Ethiopia--a community-based study.

BACKGROUND: There are reports on favourable course and outcome of schizophrenia in lowincome countries. The aim of the present study was to examine onset and clinical course of the illness in a community-based sample in rural Ethiopia based on crosssectional information. METHOD: A two-stage survey was carried out in Butajira-Ethiopia, a predominantly rural district. Altogether 68,378 individuals aged 15-49 years were CIDI-interviewed, of whom 2,159 were identified as cases according to the CIDI interview with regard to psychotic or affective disorders. Key informants identified another group of 719 individuals as being probable cases and a total of 2,285 individuals were SCAN-interviewed. The present paper reports on cases with schizophrenia. RESULTS: There were 321 cases of schizophrenia giving an estimated lifetime prevalence of 4.7/1,000). Of the cases,83.2% (N = 267) were males. Mean age of first onset of psychotic symptoms for males was 23.8 (sd 8.6) compared to 21.0 (sd 7.8) for females (P = 0.037; 95 %CI 0.16-5.47). Over 80% had negative symptoms and over 67% reported continuous course of the illness. Less than 10% had a history of previous treatment with neuroleptic medication. About 7% were vagrants, 9 % had a history of assaultive behaviour,and 3.8% had attempted suicide. The male to female ratio was nearly 5:1. CONCLUSION: This large community-based study differs from most previous studies in terms of higher male to female ratio, earlier age of onset in females and the predominance of negative symptoms.

Schizophrenia: illness impact on family members in a traditional society--rural Ethiopia.

BACKGROUND: Studies have consistently shown that both the subjective and objective dimensions of burden among family members of schizophrenia patients and other psychiatric disorders are prevalent. However, as most of these reports were from western societies, we lack information on the subject in developing countries. METHOD: The study was conducted within the framework of the ongoing epidemiological study of course and outcome of schizophrenia and bipolar disorders in a rural population of 15-49 years of age. Three hundred and one cases of schizophrenia and their close relatives participated in the study. RESULTS: Family burden is a common problem of relatives of cases with schizophrenia. Financial difficulty is the most frequently endorsed problem among the family burden domains (74.4 %). Relatives of female cases suffered significantly higher social burden (Z = 2.103; p = 0.036). Work (Z = 2.180; p = 0.029) and financial (Z = 2.088; p = 0.037) burdens affected female relatives more often than males. Disorganised symptoms were the most important factors affecting the family members in all family burden domains. Prayer was found to be the most frequently used coping strategy in work burden (adj. OR = 1.99; 95 % CI = 1.08-3.67; p = 0.026). CONCLUSION: Negative impact of schizophrenia on family members is substantial even in traditional societies such as those in Ethiopia where family network is strong and important. The scarce existing services in the developing countries should include family interventions and support at least in the form of educating the family members about the nature of schizophrenia illness and dealing with its stigma and family burden.

Socio-demographic correlates of depressive disorder in Butajira, rural Ethiopia.

OBJECTIVES: To describe the socio-demographic correlates of depressive disorder and their interactions. DESIGN: Cross sectional study. SETTING: Rural population in Ethiopia. SUBJECTS: Two hundred and twelve cases of depressive disorders. MAIN OUTCOME MEASURE: Clinically confirmed depressive disorder. METHODS: We conducted a door-to-door survey of a predominantly rural population of close to 70,000 individuals. Cases of depressive disorder were identified by use of the SCAN (Schedule for Clinical Assessment in Neuropsychiatry) and clinical assessment. RESULTS: Age was associated with the disorder: those aged 35 and above had over twice the risk of those aged 24 or below: adjusted odds ratio (95% Confidence interval) = 2.24 (1.38, 3.64). On aggregate, those previously married (separated/divorced/widowed) had an almost two-fold increased risk of the disorder compared to the singles [Adj. OR (95% CI) = 1.93 (1.00, 3.70)]. As a result of effect modification by age, being married was positively associated with depressive disorders [Adj. OR (95% CI) = 3.52 (1.96, 6.32)] among the younger age group (16 to 24 years), but this association was reversed in older (25 to 34 years) age groups [Adj. OR (95% CI) = 0.50 (0.29, 0.88)]. CONCLUSION: The study shows that age and marital status are associated with depressive disorders independently of each other and that age modifies the association of marital status with depressive disorder.

Neurological soft signs (NSS) in 200 treatment-naïve cases with schizophrenia: a community-based study in a rural setting.

Several studies have reported neurological soft signs (NSS) to be common in individuals with schizophrenia. The majority of these studies are based on clinical samples exposed to neuroleptic treatment. The present study reports on 200 treatment-naïve and community-identified cases of schizophrenia and 78 healthy individuals from the same area, evaluated using the Neurological Evaluation Scale (NES). The median NES score was 5.0 for cases of schizophrenia and 1.5 for healthy subjects. The impairment rate of NSS in cases with schizophrenia was 65.0% against 50.0% in healthy subjects, and the difference was statistically significant (chi2 = 5.30; df = 1; P < 0.021). NSS abnormality is as common in treatment-naïve cases as reported in many studies in those on neuroleptic medication. There was no significant relation between the NSS impairment and duration of illness, remission status, positive symptoms, negative symptoms and disorganized symptoms.

An evaluation of two screening methods to identify cases with schizophrenia and affective disorders in a community survey in rural Ethiopia.

BACKGROUND: Detecting cases with psychiatric disorders in the general population is costly and it is not clear which is the method of choice for community surveys in low-income countries. AIM: To compare the performance of a standardized diagnostic layman interview instrument--the Composite International Diagnostic Interview (CIDI 2.1) versus the Key Informant method in identifying cases with schizophrenia and major affective disorders in a community survey. METHOD: Both screening methods were tested against an expert interview--the Schedule for Clinical Assessment in Neuropsychiatry (SCAN 2.1) in a rural district in Ethiopia with 25,632 inhabitants. RESULT: CIDI identified 524 and key informants 192 individuals as probable cases who were invited for a further SCAN interview. Seventy-two individuals were identified by both methods. Of those identified as probable cases by either method, a total of 481 volunteered the SCAN interviews. The Key Informant method alone detected more cases of schizophrenia, 59 vs. 29 for CIDI, whereas CIDI alone detected more cases of affective disorders, 45 vs. 30. Key informants performed better in detecting chronic cases. CONCLUSION: For community surveys, which aim at identifying cases with major mental disorders in low-income countries like Ethiopia, the combined use of both CIDI and the Key Informant method is recommended.

Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia.

BACKGROUND: Many studies from the Western world have reported on stigmatisation of people with mental illnesses and its negative consequences, but few studies have addressed the issue in traditional rural societies. The present study aimed to estimate the extent and socio-demographic distribution of stigma as perceived by relatives of mentally ill individuals in rural Ethiopia. METHOD: A total of 178 relatives of individuals who were diagnosed as suffering from schizophrenia or major affective disorders in a community-based survey were interviewed using the Family Interview Schedule. RESULTS: About 75% of the respondents perceived that they were stigmatised or had experienced some sort of stigma due to the presence of mental illness in the family, 42% were worried about being treated differently and 37% wanted to conceal the fact that a relative was ill. Those from the older age group (45+) and urban residents were more likely to perceive stigma as a major problem, but otherwise differences were few between socio-demographic groups. The illness was attributed to supernatural forces by 27% and praying was suggested as a preferred method to deal with the problem by 65%. CONCLUSION: Stigma was found to be a common problem, with few differences between socio-demographic groups or between types of mental disorder. Beliefs about causes differ from those held by professionals. Popular beliefs and attitudes must be taken into account when planning for intervention.

Insulin injection technique can be taught without hospitalization.

Although hospitalization of the diabetic may be seen as a failure of management, and places the patient in an artificial situation, admission for initiation of insulin therapy is the custom in most Ethiopian hospitals. From January 1987 to January 1988, 144 diabetics were taught insulin injection technique in the Diabetic Clinic of Yekatit 12 Hospital in Addis Ababa, Ethiopia, by two nurses in early morning, six days weekly, sessions. Of these, 85 were inpatients aged 6 to 73 years from all wards, admitted because of ketoacidosis, intercurrent illnesses or rural home. The 59 outpatients, aged 7 to 70 years, attended each morning, and started therapy with 8 to 12 units of Lente insulin daily, the dose being increased every 2 or 3 days by small increments until control was attained. These outpatients needed an average of 4.7 mornings (range 1-13) to learn the technique, and an additional 3 to 4 weeks of frequent checkup to achieve control: several continued their jobs while learning. The method failed with 2 very symptomatic patients; there were no severe hypoglycaemic reactions or other complications. In addition to the financial saving for patients, and reduction of hospital bed use by diabetics, the patients helped and encouraged each other, learning faster than when taught individually as "ill" inpatients.